San Antonio Medicine September 2021

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PEDIATRIC HEALTH Early Relational Health Starts with Newborn Care

By Alice K. Gong, MD ...................................................12 Summer Surge: Off-Season Spike of RSV in Children

By Andrea Vosberg, Anna Tomotaki, Theresa Heines and Chukwudera Okolo ................................................14 SA Kids BREATHE and its Positive Impact on Pediatric Asthma By Daniel Deane, MD......................16 Manifestation and Management of Atopic Dermatitis in the Pediatric Population

By Faraz Yousefian, DO and Liliana Espinoza, BS .........18 A Guide to Common Pediatric Skin Conditions

By Ashley Chakales, Ryan Wealther, Marie Vu and John Browning, MD, FAAD, FAAP, MBA ........................20 Treatment Guidelines for Common Insect Bites Encountered in the Pediatric Population

By Faraz Yousefian, DO and Liliana Espinoza, BS .........23 Stopping Shots in the Dark: Obstacles and Opportunities to Reduce Vaccine-Preventable Diseases By Edward Dick, MD ...................................24 Changing Life Trajectories with Positive Intelligence By Charles Campbell, Jessica Glossop, Roshan George, Raudel Guerra and Joshua Kuehne .................................................................................26

SEPTEMBER 2021

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VOLUME 74 NO.9

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

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BCMS President’s Message .....................................................................................................................................8 BCMS Alliance President’s Message ......................................................................................................................10 In Memoriam: David Shulman, MD.........................................................................................................................11 Book Review: “Quackery: A Brief History of the Worst Ways to Cure Everything” By David Alex Schulz, CHP.........28 OMT in Practice: An Anecdote from a Third-Year Medical Student By Travis B. Fenlon ...........................................30 Letter to the Editor By Adam V. Ratner, MD, Reflections on Uganda—Kony's Rock by Averi White, MD .................32 55 Word Stories By Medical Students at the UT Health Long School of Medicine .................................................34 Empowering the Health Care Consumer By M. Reza Mizani, MD ...........................................................................36 Physicians Purchasing Directory.............................................................................................................................38 Auto Review: 2021 Porsche 911 By Stephen Schutz, MD......................................................................................42 Recommended Auto Dealers .................................................................................................................................44

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SAN ANTONIO MEDICINE • September 2021

SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Tim Switaj, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Melody Newsom, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Betty Fernandez, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Chinwe Anyanwu, Student Member Winona Gbedey, Student Member Teresa Samson, Student Member Niva Shrestha, Student Member Taylor Sullivan, DO, Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Danielle Moody, Editor 6

SAN ANTONIO MEDICINE • September 2021

PRESIDENT’S MESSAGE

Permitless Carry in the State of Texas

By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

Gun violence in this country is a recurrent topic covered by local and national news media. On reviewing the literature, I was amazed by the amount of data and opinionated arguments offered on both sides of this topic. It is a complex issue that deals with more than just gun laws, but also involves socioeconomic and mental status problems that I will briefly summarize.

On September 1, 2021, Texans will be allowed “permitless carry” of handguns without the need to have any training in the use of a gun. HB 1927 was signed by Governor Abbott on June 16. A University of Texas/Texas Tribune poll showed that 59% of Texas voters were against permitless carry. The Governor stated from Alamo Hall speaking of those who fought in the Alamo, “they fought for freedom, they fought for liberty and that included the freedom to be able to carry a weapon.”

A 2019 report from the Bureau of Justice Statistics shows that the adoption of the right to carry handguns was associated with a 13-15% increase in violent crimes. But do restrictive gun laws prevent gun violence? California, the state with the most restrictive gun laws, has witnessed its share of gun violence. Reviewing the top ten states with the most restrictive gun laws and comparing them to the top ten states with the fewest gun laws, there is no direct correlation between restrictive gun laws and gun-related homicides.

The same can also be said about gun ownership. The United States leads the world in gun ownership per capita, and is also among the top ten countries in the world with the most gun-related homicides.

The other countries that made the list for gun-related homicides were third world countries with high unemployment rates and high levels of poverty. In the more developed countries in the world, the statistics on gun violence are different. Europe, Finland and Switzerland have the most guns owned per capita and have some of the lowest rates of gun homicides.

Gun violence across the world can be closely linked to poverty.

The same can be seen in the United States. A 2017 PLOS Medicine study linked gun violence to poor social mobility. They found a 27% higher rate of gun-related homicides in poor neighborhoods. In-

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SAN ANTONIO MEDICINE • September 2021

equality is another measure of economic well-being, and there is a strong correlation between homicides per million and income inequality. Most of the gun violence occurs in major cities across the U.S. and in poor neighborhoods. Compared to wealthy nations, rates of violent crimes in the United States are not exceptional, though homicides remain “probably highest in the Western world,” according to a study published in 2016 by the Office of Policy Development and Research (PD&R).

With poverty comes mental stress. Mental disorders are on the rise in America, and there are multiple contributing factors, not just related to poverty. How does the ownership of handguns relate to this narrative? A study published in the NEJM last summer followed a cohort of 26.3 million adult residents in California who had not previously owned handguns from 2004 through 2016, and compared death rates among those who did not acquire handguns, with a focus on suicides by firearms versus other methods. More than 1.4 million cohort members died during the study period. Almost 18,000 of them died from suicide, of which 6,691 were suicides by firearms. According to the Centers for Disease Control and Prevention, three-quarters of 24,432-gun suicides involved handguns. In 2019, UC Davis reported of the 39,707 deaths from firearms in the United States, sixty percent were suicides.

A gun in of itself is a tool with very specific reasons for use: deterrence or to inflict injury or death. Gun violence takes this tool to a different level of analysis. Reducing gun violence in the United States is a complicated issue that involves not just ownership but also socioeconomic inequities and mental health. Prevention of gun violence will need to encompass well-designed studies that can inform future policies in three areas: 1. ownership by gun laws that are evidence-based, 2. societal inequities, and 3. improved access to mental health services. I believe it is worth considering policies that make us feel safe, whether or not we own a gun.

Rodolfo “Rudy” Molina, MD, MACR, FACP is the 2021 President of the Bexar County Medical Society.

BCMS ALLIANCE

Riding the Wave Like the rest of the medical community, Alliance members have been socially distancing, masking and urging vaccines while juggling work and family. Events like our monthly book club shifted seamlessly to a virtual format. When COVID-19 rates diminished, we were able to hold a few in-person events, a welcome respite from many months apart. We are cautiously optimistic that this fall will allow for more in-person activities, with planning for our annual Fall Luncheon underway. Outreach, a cornerstone of our Alliance, continues as we plan partnerships with Haven for Hope, BAMC Burn Center and Rudder Middle School. Regardless of the future, the BCMS Alliance is riding the wave to support our members, our physicians and our community.

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SAN ANTONIO MEDICINE • September 2021

SAN ANTONIO MEDICINE

David Shulman, MD David Shulman, MD was an ophthalmologist and a member of the Bexar County Medical Society for 47 years. He was a graduate of Creighton University School of Medicine in 1973 and completed his residency at UT Health Science Center San Antonio on June 1, 1977. Dr. Shulman joined the Bexar County Medical Society on March 1, 1974. He served as its President in 1995. Dr. Shulman was awarded with BCMS’ highest honor recognizing a lifetime of distinguished service to our patients and profession, the Golden Aesculapius Award, in January of 2020. The Bexar County Medical Society extends sympathy to the family and friends of Dr. David Shulman.

In lieu of flowers, Dr. Shulman’s family has requested donations to the Bexar County Medical Library Association. All proceeds will go towards an Ophthalmology Scholarship to a medical student/resident. Please visit this link if you would like to make a donation: https://www.bexarcv.com/secure/bcms/shulman.htm.

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PEDIATRIC HEALTH

Early Relational Health Starts with

Newborn Care

By Alice K. Gong, MD

A

newborn baby comes with the promise of a brave new world, a new beginning. For that child to become the best that he or she can be, one thousand days of nurture and nutrition is needed, starting from when that fertilized egg is implanted through the first two years of life. For the purpose of this article, due to the high rates of mental health disruptions in our pandemic society, I will focus on the importance of emotional development and nurture.

With every new life, connections between mother and baby start in-utero with the development of the autonomic nervous system (ANS). The vagus nerve, cranial nerve X, originates in the brainstem and controls autonomic functions of the heart, lungs, stomach, pharynx, larynx, trachea, esophagus and gastrointestinal tract. The sensory branch me12

diates sensations from pharynx, larynx, thorax and abdomen. It is the main component of the parasympathetic nervous system, overseeing crucial bodily functions, controlling mood, immune responses, digestion and heart rate. Afferent fibers send information about the state of inner organs to the brain. Myelination of the vagus nerve starts in the last trimester of fetal life and continues to develop through the first year. These changes ensure that the newborn can breathe, obtain food and maintain body temperature.

When birth is undisturbed and the baby is placed on the mother’s abdomen, he/she will naturally crawl to the breast, latch and suckle.

This baby crawl is driven by smell. If the breast is washed, the baby will not find the breast.

However, amniotic fluid on the breast will get the baby there. The mother will respond with

SAN ANTONIO MEDICINE • September 2021

a milk letdown. The smell of the baby also triggers an oxytocin release in the mother, which helps jump-start the emotional connection between the dyad. The pressure receptors of the baby’s body are stimulated by the crawl. When mother hugs the baby, the pressure receptors are stimulated further. Skin to skin care of the newborn calms both mother and baby, allowing the baby to access nutrients whenever he/she wants. Research has shown that blood pressure, blood sugar and temperature are better regulated. The mother’s breasts can modulate the amount of heat that the baby needs. The distance of the baby’s face latch is perfect for the newborn to see the mother. The mother will hear the baby nursing. This early reciprocal social engagement of the mother and baby continues through the newborn period, allowing

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mother and baby to develop an emotional connection and co-regulate each other. This is the basis of the nurture science, to share emotions with all the senses of smell, taste, touch, sight and hearing. It is critical for optimal family communication, behavior and development.

We know that adverse childhood experiences are associated with poor adult health outcomes. Research has shown that chronic stress activation affects early brain development, as well as wear-and-tear of multiple systems that lead to poor health outcomes.

Nurture science informs us that disruptions to the mother-infant relationship, such as the need for Newborn Intensive Care Unit (NICU) to save the baby’s life, can lead to adverse conditioning. The preterm infant’s ANS myelinates outside of the mother’s womb, and

thus cannot develop to the highest circuit of social communication. A NICU randomized controlled trial (RCT) carried out at Columbia University showed that mother-preterm baby dyads who had the services of a nurture specialist to help them emotionally connect as compared to standard care had much better neurodevelopmental outcomes up to age five.

In addition, the mothers had less anxiety and depression. We at UT Health and University Hospital (UH) participated in a replication trial with Columbia University that is near completion. Preliminary results of the primary endpoint of improved EEG power in term equivalent newborns showed that we were able to replicate the positive results of the original trial. Through the generosity of a Baptist Health Foundation grant, UH is currently implementing nurture care in the

NICU with a trained nurture specialist. This will be the first large hospital with a program that ensures the fragile NICU patients develop that important social emotional connection to their families.

Nurture science teaches us that infants can understand, react to and are developmentally influenced by the psychological states of the parents whose role is to be protector, role model and emotional navigator. As parents, we should not insulate our children. We should be able to share the good and the bad, and let them know our feelings. It is alright to have flaws and to let our children know them. Teach your young children to name their feelings – sadness, happiness, anger, fear; that no emotion is bad or wrong. Tell them that is it okay to ask for help, and how to use the tool of an honest and earnest apology. There is so much sadness in the state of the world today. Due to changes wrought by the pandemic, our shaken societies are finding that emotional intelligence is associated with resiliency. Schools are implementing social emotional learning in their curriculum.

It is time to share, communicate and find joy in everyday things with our children to help them develop resiliency.

Alice K. Gong, MD is a William and Rita Head Distinguished Chair in Developmental and Environmental Neonatology and Professor of Pediatrics at the UT Health San Antonio Long School of Medicine. She is a member of the Bexar County Medical Society.

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PEDIATRIC HEALTH

Summer Surge:

Off-Season Spike of RSV in Children

By Andrea Vosberg, Anna Tomotaki, Theresa Heines and Chukwudera Okolo

Introduction When walking through the halls of a pediatrician’s office during the cold and flu season, one is sure to be met with the unrelenting sound of coughing children. During the fall and winter months, children are commonly brought into the doctor’s office for cough, fevers, runny noses, sore throats, and, in rare cases, trouble breathing. Most of these childhood illnesses are mild and clear up with over-the-counter (OTC) medications, rest and warm chicken soup.

In typical years, when the warm weather hits, cases of these viral illnesses dramatically decline until the beginning of the next peak season. Due to the COVID-19 pandemic, masking and social distancing were in place, school was largely virtual and many children avoided sick visits to the doctor. These changes led to a much lower number of childhood viral respiratory illnesses in the winter of 2020.

As everyone knows, the COVID-19 pandemic has presented the world with many unique challenges, and the current summer season is no exception. Starting in May of 2021, pediatricians noticed a large number of babies coming into the office with viral illnesses that were not COVID-19. Instead, most of these sick children were dealing with common winter viral illnesses, most notably Respiratory Syncytial Virus (RSV).

What is RSV? Respiratory Syncytial Virus (RSV) is a common viral illness that almost all children get within the first two years of life.

The virus usually causes mild, cold-like symptoms such as runny nose and fever. Most kids will recover on their own within a week or two without any major complications. However, it can be serious, particularly for infants and older adults, as well as for people with weakened immune systems. RSV is the most common cause of bronchiolitis (inflammation of small airways in the lung) and pneumonia (infection in the lungs) in children younger than one year of age in the United States. These more serious complications are important to keep in mind when caring for a child with this illness.

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SAN ANTONIO MEDICINE • September 2021

Transmission RSV is typically spread through respiratory droplets.

When an infected person coughs or sneezes and the droplets get into the eyes, noses or mouths of others, the virus spreads. The viral particles of RSV can survive for many hours on hard surfaces and thus can be transmitted this way.

The act of touching a surface that has the virus on it (such as a table top) and then touching one’s face without engaging in proper hand washing practices in between can also result in viral spread. Direct contact with the virus, such as kissing the face of a child with RSV, is yet another way that the virus can be transmitted. People can typically spread the virus for 3-8 days after contracting RSV, however, the infected person can be contagious for up to four weeks in infants and people with weakened immune systems.

Why is it surging?

RSV typically presents in a seasonal pattern, peaking in the fall and declining by early spring. With the COVID-19 pandemic and the subsequent widespread use of masks and social distancing, many of the typical seasonal viruses did not hit their usual peak. There was a substantial 98% decrease in cases of RSV, specifically, during the pandemic. While this initially presented as an unexpected positive outcome of the pandemic, the lifting of mask and social distancing requirements over the past few months has brought with it an off-season increase in RSV cases.

This is a highly transmissible virus, so typically infants and young children are exposed to it within the first two years of life, and almost all of them catch the virus. Because of this initial exposure, children are able to build immunity to the virus if they encounter it again. However, since most children were less likely to be exposed to the virus this past year, they have a lack of immunity that most young children typically have by the end of the traditional RSV season.

This increased susceptibility has caused the uptick in cases we are seeing this summer.

PEDIATRIC HEALTH

Some more serious symptoms to watch out for are severe lethargy and/or trouble breathing. Severe infections such as pneumonia and bronchiolitis can be caused by RSV, so parental vigilance is imperative in order to ensure their child has the best possible outcome. Despite the unprecedented increase in summer cases of RSV, it is important to remember that this is a relatively mild illness. The majority of children will contract RSV at some point and then will fully recover. The best way to keep children healthy is for everyone to practice good hygiene, cover coughs and stay home when sick.

Prevention The best way to prevent the spread of RSV is to cover coughs and sneezes, wash hands often with soap and water for at least 20 seconds, avoid close contact with others, and clean frequently touched surfaces such as doorknobs and phones.

People with symptoms should avoid interaction with children who are at higher risk for severe RSV infection, including premature infants, children less than two years of age with chronic heart or lung conditions and children with weakened immune systems.

Treatment Typically, the majority of RSV infections resolve and are cleared on their own within a week or two following the onset of symptoms. There are currently no specific medications on the market indicated to treat this virus. That being said, researchers are currently working towards developing both vaccines and antiviral medications to aid in the spread and control of RSV. While there are no current prescribed treatments, there are actions that can be taken to relieve the symptoms often experienced by children infected with RSV. A few steps recommended to help mitigate symptoms include using OTC fever reducers and pain relievers, and drinking plenty of fluids to prevent dehydration. It is important to consult with a child’s health care provider before giving a child OTC, non-prescription cold medications, as some medications may contain ingredients that are not well suited for children.

Outlook Fortunately, RSV tends to have a positive outlook for the majority of children who contract the virus. Mild symptoms such as sneezing, coughing and runny nose are the typical inconveniences experienced by infected children. One of the most important actions a parent can take is monitoring their child’s symptoms to ensure their child does not get sicker.

References Centers for Disease Control and Prevention. (2020, December 18). Rsv (respiratory syncytial virus). Centers for Disease Control and Prevention. https://www.cdc.gov/rsv/index.html.

Olsen SJ, Winn AK, Budd AP, et al. Changes in Influenza and Other Respiratory Virus Activity During the COVID19 Pandemic — United States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021;70:1013–1019. DOI: http://dx.doi.org/10.15585/mmwr.mm7029a1 Agha, R., & Avner, J. R. (2021). Delayed seasonal rsv surge observed during the covid-19 pandemic. Pediatrics. https://doi.org/10.1542/peds.2021-052089

Pictured: UT Health San Antonio Long School of Medicine’s Pediatric Interest Group officers. Andrea Vosberg (second from left), Anna Tomotaki (center), Chukwudera Okolo (third from right) and Theresa Heines (second from right) are medical students at the UT Health Long School of Medicine.

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PEDIATRIC HEALTH

SA KIDS BREATHE

and its Positive Impact on Pediatric Asthma

By Daniel Deane, MD

A

sthma is a complex inflammatory process. Many external factors impact asthma control and are difficult to identify in the short time frame of an office visit.

All home triggers may not be revealed, nor detrimental social determinants exposed. SA Kids BREATHE (SAKB) is a free city program that provides a comprehensive assessment of the home and uncovers adverse social determinants. SA Kids BREATHE stands for Building Relationships, Effective ASTHMA Teaching in Home Environments. These children are in need of physician referrals.

The heart of a successful therapeutic relationship is effective communication between the physician and the patient. The more time a physician spends with a patient, the better the outcome. The current health care environment emphasis on productivity may undermine this relationship.

SAKB is not a replacement for the physician but works to reconnect patients with their caretakers and expand the physician’s impact on education. It provides insights into the home environment and shows social determinants’ detrimental impacts, which will help guide therapeutic decisions.

Trained Community Health Workers (CHWs) meet the family and child where they are—in-home or virtually—to educate children and their families about effective ways to control asthma. The CHWs make five to six visits with the families over a sixmonth period. Three to four visits are at home and last for one hour. One visit is with a health care provider, and one is with the child’s school or daycare.

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Each CHW is guided by a certified Registered Respiratory Therapist and Certified Asthma Educator with more than 30 years of experience. And, the CHWs are working towards becoming Certified Asthma Educators.

The in-home visits are valuable because they offer the CHWs a chance to make assessments that are difficult in a clinic environment. They apply the Environmental Protection Agency’s Asthma Environmental Checklist to the home environment to identify and remediate triggers. They also recognize social determinants affecting a child’s asthma control and provide help and support.

When the CHWs educate children and their families at their homes, it gives physicians more time to implement therapeutic changes when the patient comes to the clinic, reinforcing the bond between the physician and patient. The CHW can visit the clinic with the family, allowing for timely identification of concerning changes in their child’s symptoms. The CHW also is a direct line of communication with the school nurse. Communications with physicians and nurses can be maintained through secure email (if the clinic has capabilities), direct telephone contact and/or fax.

The fundamental principles of SAKB are successful in providing self-management skills to asthma patients in similar programs throughout the country1,2 and represent the tenets of value-based care. SAKB maintains proper medication delivery skills, identifies and removes irritant and allergic triggers in the home and recognizes the contribution of allergies that may need more extensive evaluation.

SAN ANTONIO MEDICINE • September 2021

For more information about SA Kids BREATHE and to find the one-page referral sheet, please visit www.sanantonio.gov/ SAKidsBREATHE or call 210-207-7282.

For secure referrals, fax 210-207-9757 or use a secure email to send to SAKidsBREATHE@sanantonio.gov.

References 1. Marshall ET, Guo J, Flood E,Sandel MT, Sadof MD, Zotter JM. Home Visits for Children With Asthma Reduce Medicaid Costs. Prev Chronic Dis 2020; 17:190288.

DOI: https://doi.org/10.5888/pcd17.

190288 2. Shreeve K, Woods ER, Sommer SJ, et al.

Community Health Workers in Home Visits and Asthma Outcomes. Pediatrics.

2021;147(4): e2020011817 Daniel Deane, MD is a retired Pediatric Pulmonologist. He is on the Advisory Council of SA Kids BREATHE and is a member of the Bexar County Medical Society.

PEDIATRIC HEALTH

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PEDIATRIC HEALTH

Manifestation and Management of Atopic Dermatitis in the Pediatric Population

By Faraz Yousefian, DO and Liliana Espinoza, BS

A

topic dermatitis (AD), or eczema, is one of the most common dermatological conditions physicians encounter in the pediatric population. The standard of care for these dermatological conditions can provide both physical and psychosocial relief to the patients and their caregivers. For this reason, it is of paramount importance to understand its causes, symptoms and best treatment options available to mitigate its effects.

AD is an allergic spectrum disorder that affects 20% of children with a prevalence of 60% in the first year of life and 90% in the first five years of life.1-3 Additionally, approximately 60% of AD cases persist into adulthood, with 15% of patients later developing

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a food allergy, allergic rhinitis and/or asthma.1-3 The majority of AD patients have a family history of AD, as the risk of developing AD can increase 2-5-fold if both parents have AD.1,3 The pathophysiology of this disease is characterized by a decreased expression of the structural protein filaggrin, a decrease in ceramide lipid, increased protease expression, and immunologic abnormalities related to interleukin 4 and 13, which in conjunction affect the integrity of the skin barrier.3 Namely, these abnormalities lead to increased skin pH, decreased hydration, decreased S. aureus resistance, increased susceptibility to allergens and disorders of keratinization.1,3

SAN ANTONIO MEDICINE • September 2021

The Hanifin-Rajka (H-R) criteria is considered the gold standard diagnostic criteria for AD; however, it is not utilized by all allergists or dermatologists.2,4,5 AD is commonly diagnosed based on history and physical presentation; however, immunodeficiency conditions such as Hyper-IgE syndrome and Omenn syndrome should be ruled out initially.3 The cutaneous findings resulting from AD are commonly located on the face, scalp and flexor body surfaces.1,3,5 AD manifestations include dry skin accompanied with severe pruritis; erythematous maculo-papular rashes; vesicles that can have exudate and crusting (acute flare); dry, scaly excoriated patches (more chronic lesions);

PEDIATRIC HEALTH

lichenification (chronic); hyper/hypopigmentation; and excoriations at various stages of healing.4 In addition to the classic clinical features of AD, a patient can also experience extensive psychosocial discomfort. For example, patients with AD may exhibit persistent fidgeting due to pruritis, irritability, insomnia due to pruritis at night and decreased concentration.4,5 AD complications can also include an increased susceptibility to contracting infections with bacteria, herpes simplex infections, molluscum contagiosum and warts.4 Management of AD is multifaceted. Treatment can be given daily based on the chronicity of the disease, is highly personalized to the patient based on its severity and often requires review at follow-up visits to ensure patient compliance. First and foremost, avoidance of triggers (allergens and irritants) in fragrances, clothing, temperature extremes, foods and soaps/detergents can reduce the incidence and severity of AD.2,4 To help stabilize and reduce acute flares, patients can benefit from moisturization of the skin and application of topical steroids, topical calcineurin inhibitors (pimecrolimus and tacrolimus), topical phosphodiesterase-4 inhibitor (Crisaborole), injectable Dupilumab and/or oral antihistamines.2,5 Moreover, early evidence suggests that limiting the use of skin cleansers and applying an oil-in-water emollient at least once daily may lower the risk or decrease the severity of AD.2,4 In general, the thicker and greasier the emollient, the higher the content of oil relative to water and the more effective the emollient (e.g., ointment is better than cream, which is better than lotion). Although water exposure can increase xerosis through evaporative loss, daily baths hydrate the skin, especially if the water loss is prevented by emollient application within a few minutes after bathing.2,4 In severe cases, there are other treatment options that can be

implemented such as bleach baths, phototherapy, hospitalization for intense eczema care and systemic immunosuppressants (Cyclosporine and Methotrexate).2,4,5 Once the eczema is stable, food allergy concerns should be addressed. Lasty, topical and oral antibiotics can also be prescribed as needed to treat superinfections.4 AD is one of the most common ailments affecting the skin, especially in children.

Treatment options are varied and can be highly customized for a patient, depending on the severity of his or her AD. Still, new therapeutic avenues are constantly being explored, such as those investigating the role of probiotics in treating AD, to ensure that patients achieve more efficacious management of their condition.4 References: 1. Hanifin JM. Atopic dermatitis. Journal of the American Academy of Dermatology.

1982;6(1):1-13. doi:10.1016/S01909622(82)70001-5 2. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. Journal of the American Academy of Dermatology. 2014;70(2):338-351. doi:10.

1016/j.jaad.2013.10.010 3. Abramovits W. Atopic dermatitis. Journal of the American Academy of Dermatology. 2005;53(1):S86-S93. doi:10.1016/ j.jaad.2005.04.034 4. Fishbein AB, Silverberg JI, Wilson EJ, Ong PY. Update on Atopic Dermatitis: Diagnosis, Severity Assessment, and Treatment Selection. J Allergy Clin Immunol Pract.

2020;8(1):91-101. doi:10.1016/j.jaip.2019.06.044 5. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013;131

(2):295-299.e1-27. doi:10.1016/j.jaci.20 12.12.672 Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general populous about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

Liliana Espinoza, BS is currently a Ph.D. candidate in the field of neuroscience at UT Health San Antonio where she studies the early effects of a high fat diet on the motor neurons that innervate the heart. She will be pursuing a medical degree upon completion of her doctoral degree.

Visit us at www.bcms.org

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PEDIATRIC HEALTH

A Guide to Common Pediatric Skin Conditions

By Ashley Chakales, Ryan Wealther, Marie Vu and John Browning, MD, FAAD, FAAP, MBA

S

kin conditions are commonly encountered in the primary care clinic. In this article, we highlight four common pediatric skin conditions often encountered by primary care physicians, including clinical pearls and when a referral to a dermatologist is warranted.

Atopic Dermatitis Atopic Dermatitis (AD) affects 11-12% of children in the United States. Several mechanisms have been proposed for the pathophysiology of AD, including epidermal barrier dysfunction, immune dysregulation, genetic predisposition, as well as environmental triggers.6 The classic lesion is a pruritic, erythematous rash (Figure 1). The distribution differs with age, with the face and extensors primarily affected in children ages 0-2 years and flexural surfaces primarily affected in adolescents. Common treatments for AD include gentle skin care practices (mild cleansers and bland emollients), topical corticosteroids and non-steroidal topicals (topical calcineurin inhibitors, topical phosphodiesterase-4 inhibitors).

Figure 1:

Clinical Pearls: A common mistake in the management of AD is undertreatment.5 “Topical steroid phobia” is prevalent among patients because misinformation regarding potential side effects is often Image: Procedural Pediatric Dermatology8 overemphasized 9 on the internet. Providers play an important role in debunking inaccurate information to increase treatment adherence. Additionally, the

diagnosis of AD in skin of color patients is challenging because erythema may be difficult to visualize.2 It is always important to ask about pruritus, as it is the hallmark symptom of AD. When to refer: A referral to a dermatologist is recommended when attempts at initial management have not been successful, the patient has frequent flare-ups or the condition is causing psychosocial disturbance.

Allergic Contact Dermatitis Allergic contact dermatitis (ACD) is a type four hypersensitivity reaction consisting of two phases: sensitization followed by elicitation.

During sensitization, a hapten penetrates the skin and forms an antigen complex, inducing an immune response. Upon re-exposure to the same culprit, immune cells recognize and process the allergen and induce a local inflammatory response. The classic lesion is a localized, pruritic, eczematous eruption (Figure 2). Common culprits include poison ivy, nickel, topical antibiotics (neomycin, bacitracin), fragrance and preservatives.10 Figure 2:

Image: Procedural Pediatric Dermatology8

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SAN ANTONIO MEDICINE • September 2021

PEDIATRIC HEALTH

Clinical Pearls: It can be difficult to elicit the cause of ACD when it is from an everyday product. Fragrance, preservative and topical antibiotic allergy are notoriously difficult to diagnose. Allergy to neomycin or bacitracin often resembles an infection and can lead to inappropriate use of oral antibiotics.

When the cause of ACD is unknown, a gentle skin care routine can be recommended. This includes use of a fragrance-free bar soap, a bland emollient, and hypoallergenic shampoo and conditioner. Once the dermatitis subsides, slow reintroduction of normal products can begin until the allergen is determined.

When to refer: When the offending agent causing ACD cannot be identified, a referral to a dermatologist will be beneficial. An extended patch testing can be performed to determine the underlying allergies and develop a treatment plan.

When to refer: Most tinea infections respond well to antifungal medications. Referral to a dermatologist should be considered when the presentation is severe or recalcitrant, such as a kerion with tinea capitis or Majocchi’s granuloma with tinea corporis.

Acne Vulgaris Acne is very common among adolescents and young adults, with nearly 85% of teenagers affected at some point (Figure 4). The understanding of acne is constantly evolving, but is thought to involve a combination of factors such as follicular hyperkeratinization, sebum production, genetic factors, and diet, among other causes. There is currently no universal grading system to assess severity of acne; however, classifying acne based on number, type and location of lesions can help facilitate therapeutic decisions. The treatment for acne depends on the severity.12 Figure 4:

Tinea Tinea infections are caused by fungi known as dermatophytes and are classified by the involved site. The classic lesion is an erythematous, scaly plaque with an active border that spreads centrifugally and is followed by central clearing (Figure 3). This is where tinea gets its common name: ringworm. While most tinea infections are more common in adults, tinea capitis is more common in children.3 It usually presents as localized alopecia with scaling. Tinea capitis requires prolonged treatment with oral antifungals, as topical antifungals do not reach the root of the hair follicle.

Figure 3:

Image: Centers for Disease Control and Prevention 4

Image: Procedural Pediatric Dermatology8

Clinical Pearls: Griseofulvin for 6 to 12 weeks is the first-line therapy for tinea capitis;11 however, the effective dose for griseofulvin (20 to 25 mg/kg/day) has increased from what was previously recommended (10 to 15 mg/kg/day).7 It is not uncommon to see sources still list the lower dose (e.g., Epocrates). Utilization of this low dose is a common reason for treatment failure and referral to dermatologists. It is also important to recommend that griseofulvin be given in a single daily dose (better compliance than with BID dosing) and with a fatty meal11 (better absorption). Additionally, hepatic monitoring with griseofulvin is unnecessary unless treatment extends beyond 8 weeks.7

Clinical Pearls: Topical retinoids, which are some of the most effective treatment options for acne, are often underutilized. Many providers tend to reserve topical retinoids for comedonal acne, even though they have a role in effectively treating inflammatory acne.1 Counseling patients on the purpose of medications prescribed, how to correctly use them, side effects to expect, and the time frame for which they can expect noticeable results is important for medication adherence. Irritation from topical retinoids is common and expected, often resolving after a few weeks of treatment. continued on page 22 Visit us at www.bcms.org

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PEDIATRIC HEALTH continued from page 21

When to refer: The following all warrant a referral to a dermatologist: abrupt onset of extensive acne, no improvement with conservative management, cystic or nodular acne that is considered moderate to severe, new onset of acne after initiation of systemic medication, and acne that is negatively affecting psychosocial well-being.12 References: 1. Balkrishnan, R., Fleischer Jr, A., Paruthi, S., & Feldman, S. (2003).

Physicians underutilize topical RETINOIDS in the management of acne vulgaris: Analysis of U.S. National practice data. Journal of Dermatological Treatment, 14(3), 172-176.doi:10.1080/095466 30310012037 2. Ben-Gashir, M., Seed, P., & Hay, R. (2002). Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts. British Journal of Dermatology, 147(5), 920-925. doi:10.1046/j.1365-2133.2002.04965.x 3. Bolognia, J., Schaffer, J. V., Duncan, K. O., & Ko, C. J. (2014). Dermatology essentials. Oxford: Saunders/Elsevier.

4. Centers for Disease Control and Prevention [Ringworm]. (2021).

Retrieved from https://www.cdc.gov/fungal/diseases/ringworm/ symptoms.html.

5. Fishbein, A. B., Hamideh, N., Lor, J., Zhao, S., Kruse, L., Mason, M., . . . Kaye, B. (2020). Management of atopic DERMATITIS in children younger than two years of age by COMMUNITY PEDIATRICIANS: A survey and chart review. The Journal of Pediatrics, 221. doi:10.1016/j.jpeds.2020.02.015 6. Kim, J., Kim, B. E., & Leung, D. Y. (2019). Pathophysiology of atopic dermatitis: Clinical implications. Allergy and Asthma Proceedings, 40(2), 84-92. doi:10.2500/aap.2019.40.4202 7. Kimberlin, D., Barnett, E., Lynfield, R., & Sawyer, M. (2021). Red Book (2021): Report of the Committee on Infectious Diseases, 32nd Ed. Itasca, IL: American Academy of Pediatrics.

8. Krakowski. (2021). Retrieved from Procedural pediatric dermatology.

9. Li, A. W., Yin, E. S., & Antaya, R. J. (2017). Topical corticosteroid phobia in atopic dermatitis. JAMA Dermatology, 153(10), 1036. doi:10.1001/jamadermatol.2017.2437 10.Novak-Bilić, G. (2018). Irritant and allergic contact dermatitis – skin lesion characteristics. Acta Clinica Croatica. doi:10.20471/ acc.2018.57.04.13 11.Treat, J.R. (2021). Tinea Capitis. UpToDate. Retrieved August 8, 2021, from https://www.uptodate.com/contents/tinea-capitis 12.Zaenglein AL, Pathy AL, et al. (2016). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 74, 945-973. doi:10.1016/j.jaad.2015.12.037

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Ashley Chakales, Ryan Wealther and Marie Vu are medical students at the UT Health San Antonio Long School of Medicine. They all serve as leaders of the school’s Dermatology Interest Group.

John Browning, MD, FAAD, FAAP, MBA is board-certified in pediatrics, dermatology and pediatric dermatology. He is an adjunct associate professor at UT Health San Antonio, assistant professor at Baylor College of Medicine and clinical faculty at the UIW School of Medicine.

PEDIATRIC HEALTH

Treatment Guidelines for Common Insect Bites Encountered in the Pediatric Population

By Faraz Yousefian, DO and Liliana Espinoza, BS

O

ne of the most common ailments affecting the pediatric population is insect bites. Dermatologic eruptions can manifest in a variety of ways, depending on the severity and toxicity of the specimen that inflicted the bite. Because the resultant dermatological conditions can induce not just physical but also psychosocial discomfort to the patient, it is of paramount importance that physicians implement the appropriate standard of care procedures.

The Texas pediatric population spends an appreciable amount of time in outdoor settings, making the likelihood of being in contact with insects unavoidable. The body's reaction to a given insect’s saliva, secretion and/or remains can widely manifest from benign to life-threatening conditions. The most common benign cutaneous findings include localized swelling, burning, pruritus and pain.1-5 However, in immunocompromised individuals, symptoms might also include bullae or pruritic papule-like eruptions.1,6 Arthropods are the primary culprits of these dermatological conditions, and can be classified as venomous (e.g., bees and fire ants) and nonvenomous (e.g., mosquitos, ticks, mites, flees, chiggers, scabies, spiders, scorpions and body lice).2-3 Venomous or stinging insects can also trigger systemic constitutional reactions such as anaphylaxis.2-3 The first line recommendation to reduce the likelihood of an arthropod bite is wearing insect repellent products containing DEET; protective, non-bright colored clothing; and unscented skin and hair formulas.2 After an insect bite, however, a patient may find relief by applying a cool 25% menthol and camphor product compress and topical pramoxine or lidocaine anesthetics over the area.3 Topical diphenhydramine and benzocaine should not be advised, for they might trigger contact dermatitis.3 The inflammatory reaction can be relieved with sedative oral an-

tihistamine (e.g., hydroxyzine 25 mg every 68 hours, as needed), non-sedative antihistamine (e.g., fexofenadine 60 mg every 12 hours) or psychotherapeutic agents (e.g., doxepin 25 mg every 24 hours at bedtime).2-3 In addition, high potency (class 1-2) topical steroids can be applied to the lesions on the trunk and extremities every 12 hours to relieve the inflammation and itch.2-3 In the case of severe anaphylaxis, treatment typically consists of vasoactive medications, fluids and systemic steroids to prevent the progression of the illness and stabilize the patient.2-3 It should be noted that specific treatment options are available for certain arthropods. For instance, scabies is preferably treated with permethrin; lice with permethrin or malathion; Lyme disease with antibiotics; and spider bites, such as those involving the brown recluse spider, which can be treated with dapsone or non-steroidal antiinflammatory drugs (NSAIDS).2-4 Additionally, in cases where a tick bite is detected, a tick remover tool or tweezers must be used immediately to remove the tick from the skin, and the area should be washed with soap and water.7 Given the likelihood of insect bites in the pediatric population, it is important that the appropriate measures be taken to prevent and treat the resultant dermatological conditions.

Prophylactic measures are most effective; however, therapeutic options are available for a wide variety of arthropod-induced skin lesions. Still, given that symptoms can range from mild to severe, medical attention should be sought out in the most severe cases involving anaphylactic shock.

References: 1. Powers J, McDowell RH. Insect Bites. In: StatPearls. StatPearls Publishing; 2021.

Accessed August 8, 2021. http://www. ncbi.nlm.nih.gov/books/NBK537235/

2. Juckett G. Arthropod bites. Am Fam Physician. 2013;88(12):841-847.

3. Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatology. J Am Acad Dermatol. 2004;50(6):819-842, quiz 842-844. doi:10.1016/j.jaad.2003.12.019 4. Casale TB, Burks AW. Clinical practice.

Hymenoptera-sting hypersensitivity. N Engl J Med. 2014;370(15):1432-1439. doi:10.1056/NEJMcp1302681 5. Goddard J, Jarratt J, de Castro FR. Evolution of the fire ant lesion. JAMA. 2000;284(17):2162-2163. doi:10.1001/jama.284.17.2162 6. Biting Insects | JAMA Dermatology | JAMA Network. Accessed August 8, 2021. https://jamanetwork.com/journals/jamadermatolog y/articleabstract/533062 7. Ackerman AB, Metze D, Kutnzer H. Erythematous papules and nodules after tick bite.

Am J Dermatopathol.

2002;24(5):427-428. doi:10.1097/00000 372200210000-00010

Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general populous about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

Liliana Espinoza, BS is currently a PhD candidate in the field of neuroscience at UT Health San Antonio where she studies the early effects of a high fat diet on the motor neurons that innervate the heart. She will be pursuing a medical degree upon completion of her doctoral degree.

Visit us at www.bcms.org

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PEDIATRIC HEALTH

Stopping Shots in the Dark: Obstacles and Opportunities to Reduce Vaccine-Preventable Diseases

By Edward Dick, MD

Introduction The current COVID-19 health emergency underscores the challenges and importance of preventing disease before it occurs through an effective immunization program. A coalition of the American Cancer Society and ImmunizeSA conducted a survey to identify current states of awareness, opportunities and obstacles to achieving optimal immunization. The 15-item survey was conducted online with participants from the Bexar County Vaccines for Children (VFC) Program, Bexar County Chapter of the Texas Academy of Pediatrics and physician members of the Bexar County Medical Society (BCMS). The survey was conducted from January to April 2020 and had an 85% response rate (107 total respondents). Of the respondents, 42% were in private practice, and 96% of the respondents participated in the VFC program. Respondents included multiple practice roles, including medical assistants, nurses, physicians and other medical providers. The survey consisted of 10 general immunization questions and five optional questions on HPV vaccinations (79% response rate).

Lessons Learned: Highlights Of the respondents, 81% reported using standing orders to administer Advisory Committee on Immunization Practices (ACIP) recommended vaccines. Ninety nine percent of the respondents indicated that their ACIP standing orders include HPV vaccinations. Almost all the respondents (99%) indicated familiarity with the ImmTrac2 immunization registry, and 94% knew that in Texas, pediatric patients who turn 18 years old must consent again into ImmTrac2 when they turn 18.

On the optional HPV vaccine survey, providers were asked to respond to questions about general knowledge of the human papilloma virus, the HPV vaccine and issues related to its administration. Figure 1 illustrates eight items related to the HPV vaccine.

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SAN ANTONIO MEDICINE • September 2021

Figure 1: What do you understand to be true about the HPV vaccine?

HPV vaccine is cancer prevention

95.95%

2 doses should be given to patients 9-14 years of age.

95.95%

3 doses should be given to patients above the age of 15 years

93.24%

The vaccine is safe for both males and females

97.30%

The HPV Vaccine prevents six types of cancers

54.05%

The HPV Vaccine is safe, and the only known side effects are mild, like those of other vaccines

87.84%

A common method for administering the vaccine is "Same Day, Same Way." This method encourages administration of the HPV vaccine while also administering other age-appropriate vaccines 81.08% I am not familiar with the HPV Vaccine

2.70%

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Responses indicated high awareness and agreement that the HPV vaccine prevents cancer, however, only slightly more than half of the respondents knew that it prevented six types of cancer.

Figure 2 illustrates the barriers respondents encountered to HPV vaccination. According to the respondents, there were three main barriers to patient adoption of the HPV vaccine. Respondents indicated that parents/patients had concerns about the vaccine (76%), parents refused the vaccine (81%) and the lack of requirement for school entry hinders vaccine adoption (65%). In contrast to the role of parent refusal of the vaccine, only 31% of the respondents indicated patient refusal was an impediment to vaccine adoption. Cost was a barrier in less than 7% of the cases.

Figure 2: What barriers have you experienced with the HPV vaccine?

Discussion The survey indicated a high level of participation and an awareness of the importance of vaccines on the part of medical providers. Continued barriers to successful vaccination include techniques to address and work through parent objections to HPV vaccines. One successful approach to parental and patient objections has been the “same way, same day” techniques of the American Cancer Society that normalize the HPV vaccine as a natural complement of recommended vaccines.

While respondents indicated an awareness that the HPV vaccine prevents cancer, they were not as aware of the six types of cancers that it prevents. Greater awareness of the extent and types of cancers on the art of both provider, parents and patients may shift the debate and make more people take the vaccine. Both the Immunize SA and American Cancer Society offer extensive resources on vaccines for patients in general and doctors to increase immunization coverage and reduce vaccine-preventable diseases. During the COVID Public Health Emergency (PHE) the value and challenges of preventing disease through effective immunizations is more apparent.

Acknowledgements Thank you to the American Cancer Society South Texas HPV Vaccination Task Force and Metro Health for conducting the survey and compiling the results in this study.

Resources American Cancer Society https://www.cancer.org/health-care-professionals/hpv-vaccinationinformation-for-health-professionals/hpv-vaccination-resources-forhealth-professionals.html Immunize SA h t t p s : / / w w w. i m m u n i z a t i o n c o a l i t i o n s . o r g / n e t w o r kmembers/?coal=immunize-san-antonio-izsa_oid353 ImmTrac2 https://www.dshs.texas.gov/immunize/immtrac/default.shtm Edward Dick, MD is the Director of Clinical Complex Care Management at Methodist Healthcare Ministries. He is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

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PEDIATRIC HEALTH

Changing Life Trajectories with Positive Intelligence

By Charles Campbell, Jessica Glossop, Roshan George, Raudel Guerra and Joshua Kuehne

The effects of the COVID-19 pandemic restrictions impacted more than just the capacity of Bexar County health systems and the local economy. For our most vulnerable and at-risk adolescent populations, the restrictions amplified pre-existing social inequalities and led to increased incidences of distress, anxiety and depression as a result of the mandated internal displacement and social isolation imposed on our youth.1 Without question, the psychological and mental health impacts of the COVID-19 pandemic will have lasting effects on Bexar County youth with regard to educational and career goals. To mitigate these negative effects, an ambitious team of medical students at the UIW School of Osteopathic Medicine (UIWSOM) partnered with Southwest Independent School District (SWISD) through a community engagement partnership (CEP) project and developed an educational video series to provide high school juniors and seniors positive intelligence and mindfulness training. Dr. Leticia Vargas, the team’s lead advisor, made it clear that "if something isn't done to change the life trajectory of these high school students, their ability to take advantage of opportunities for meaningful careers will be limited. Teaching them the value of positive intelligence is one way to help alter their trajectory and bring them closer to their educational and career goals."

The Positive Intelligence (PQ) training is based on the book Positive Intelligence by Shirzad Chamine. It is the science and practice of developing mastery over your own mind so you can reach your full potential for both happiness and success. PQ is based

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around an understanding of saboteurs, the agents of self-sabotage, that represent your brain's automatic habits used to handle life’s challenges. There are ten saboteurs (harmful, innate stress-coping mechanisms) that include the Judge, Controller, Avoider, Victim, Stickler, Pleaser, Hyper-Achiever, Hyper-Vigilant, Restless and Hyper-Rational. Through weakening of the saboteurs and development of one’s sages (beneficial positive emotions) - activate, explore, innovate, navigate and empathy - a person can increase their positive intelligence score, which can lead to increased success and happiness.2 The PQ series’ adaptability for a younger audience was the primary reason it was selected as the model for the CEP. The CEP targeted underserved and disadvantaged high school juniors and seniors in SWISD. The majority of the student body are Hispanic with 74.6% of students coming from economically disadvantaged backgrounds.3 In addition, the majority of students at this school are classified as “at risk” for dropping out of school based upon criteria established at the state level. When it comes to college readiness, the students are

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achieving SAT and ACT scores that are below the statewide average.

The COVID-19 mandated restrictions caused students to struggle with learning, impacting their ability to reach their academic achievement goals. This project sought to teach students skills to foster a mindset that promotes greater achievement while learning to address mindsets that may limit their growth. Without intervention, it was hypothesized that some students may continue down a path that would prevent them from achieving their full potential. Therefore, the project was developed with the intentions of challenging the student’s mindset, along with their habits, so they can achieve their highest potential and continue to grow.

Valerie Gutierrez, the SWISD Health Science Department Lead, aided the team in targeting a population of approximately 90 students, all of whom are dually enrolled in the school’s medical assistant certification program. These students were able to complete the mindfulness training during specified time periods in class with technology platforms available through the school. An understanding of the student population

PEDIATRIC HEALTH

and technology access allowed the team to select the appropriate media to ensure the best results.

For the purposes of training and education, a series of twelve videos consisted of ten training modules and two summary and follow-up/assessment modules. Each of the ten training videos discussed one of the saboteurs outlined in the PQ book. The videos introduced a character, similar to a pop culture icon, that the students could easily identify with. The character was described as embodying one of the saboteurs to aid students in understanding how the saboteur could negatively impact their life and how they could properly identify it. The video would end with an explanation of how to activate the sages and utilize mindfulness techniques to overcome the saboteur and increase the students’ PQ. The students were given PowerPoint slides from the videos to track and take notes as they watched them. Along with the link to the PQ “Self-Assessment” website, they could choose to take a free self-assessment to determine where their emotional strengths and weaknesses resided on the scaled continuum. The training was initiated and completed over a course of six weeks during the 2021 spring semester.

Dates were set up in May to allow for a virtual discussion and follow-up between the team and the students. This discussion would address the subjects, ideas, concepts and lessons learned during the mindfulness training program and answer questions. Ms. Gutierrez was able to provide the team with her personal impression of the outcomes of the training, “Through the collaboration with the UIWSOM,” she explained, “we were able to bring awareness to students, by highlighting some of the tools and techniques that could lead to achieving their full potential under less-than-ideal situations. I believe, wholeheartedly, the more students that are

made aware and educated early, the better prepared they can be in their personal and professional lives.”

Ultimately, by improving mental health advocacy and strengthening the bonds between the medical learners at UIWSOM and the community, the team hopes to spark interest in our Bexar County adolescent population to pursue a career in medicine. Dr. Vargas stressed, "having experiential moments where high schoolers can interact with medical learners and having that human connection allows them to see themselves in each and every one of us and realize that they too are capable of achieving a medical career.

Every kid needs a champion."

Charles Campbell, Jessica Glossop, Roshan George, Raudel Guerra and Joshua Kuehne are all students at the UIW School of Osteopathic Medicine and members of the CEP Team.

References: 1. Loades, M. E., Chatburn, E., HigsonSweeney, N., Reynolds, S., Shafran, R., Brigden, A., . . . Crawley, E. (2020). Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Journal of the American Academy of Child & Adolescent Psychiatry,59(11). doi:10.1016 /j.jaac.2020.05.009 2. Chamine, Shirzad. Positive Intelligence (PQ), Greenleaf Books Group Press (2012). https://www.positiveintelligence.com. Positive Intelligence training is focused on improving a person’s “mental fitness,” using neuroscience, cognitive and positive psychology, and performance science.

3. The Texas Tribune. (2018). Southwest High School. https://schools.texastribune.org/districts/southwest-isd/southwest-high-school/

Visit us at www.bcms.org

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BOOK REVIEW

An Analysis of “Quackery: A Brief History of the Worst Ways to Cure Everything”

By David Alex Schulz, CHP

When authors Lydia Kang and Nate Pedersen approached the “Worst Ways to Cure Everything,” they faced a challenge of balance: much of this history is morbidly humorous while equally serious: fraud in health care is not only still with us, but as prevalent as ever. To recount history’s phony, ineffective or poisonous attempts at healing calls for an approach that neither forces the book into a tour of Ripley’s Hall of Horrors or a Rube Goldberg’s Sunday Funnies, the truth is far more ambiguous.

As Kang and Pederson explore the history of false and fraudulent health care therapies, we learn that with many substances and forces, a little can go a long way to good effect; but a lot, on the other hand, might only go about six feet … vertically.

Take the Russian Electric Shower, a perfect example of excess. When electricity was harnessed by Alessandro Volta and Luigi Galvani, they discovered the muscles of a dead frog’s leg twitched when struck by an electric spark. If electricity brings motion to the dead, it must certainly benefit the living! (One can see Mary Shelley lurking in the literary background.)

Early medical uses of For shocks and giggles: a Russian electricity shocked paElectric Shower. tients suffering from rheumatism, malignant fever and the plague.

Electric baths were advertised to help with a variety of chronic conditions such as gout and sciatica, the justification for the Russian Electrical Shower.

By the end of the 19th century, electric hairbrushes, corsets, belts and a device to cure erectile dysfunction were marketed for the DIY electro-therapy enthusiast. Ironically, this coincides with the incorporation of electricity for “humane” execution.

Even today, products are pulled off the shelf for electrocuting in the name of health. In 1996, the Executive Briefcase, a top-of-the line Elec28

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tronic Muscle Stimulator (EMS) machine, was yanked by the FDA for causing cardiac arrhythmias. More recently, the FDA has received reports of shocks, burns, bruising, skin irritation and pain associated with the use of some of these devices.

There have been a few recent reports of interference with implanted devices such as pacemakers and defibrillators. Some injuries required hospital treatment.

We also know, of course, that carefully controlled application of electricity is extraordinarily beneficial to patients, from pacemakers and defibrillators to instrumentation like the EKG and EEG. This is the key to making “Quackery” such an enjoyable read. The authors end each topic with a reflection of our current use of some previously, terribly abused chemical, organic material, instrument, animals (think leeches), or “mysterious power” like electricity, light and radionics.

They begin with the manifold and bizarre medical uses of mercury.

This silvery, unique liquid metal was assumed to have great powers, and it did: the power to purge. Marketed under the name Calomel, Mercurous Chloride was the “go to” laxative for many decades. For example, Lewis and Clark were given 1,300 of “Dr. Benjamin Rush’s Famous THUNDERCLAPPERS.” It proved so effective an evacuant that the expedition’s progress can be traced by remnants of mercury in the soil a “latrine’s length” from their trail.

Mercury had been applied to treat syphilis from the 15th century through recent times. “Niccolò Paganini, one of the most famous violinists in history, likely suffered from mercury toxicity after he was diagnosed with syphilis … shaking uncontrollably, contributing to his withdrawal from the stage in 1834,” write the authors.

Mercury’s toxicity is well-accepted but still makes its presence in health care, symbolically at least. The god’s symbol, the caduceus of two entwined snakes on a winged rod, is often mistaken for the proper symbol of physicians: the Rod of Asclepius, a single snake on a simple rod.

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Arsenic’s deadliness made it an early favorite for homicide-by-poison – odorless, often tasteless and easily concealed. It has also been used since antiquity as a medicinal.

“It’s an escharotic, which means it causes the skin surface to die and slough off … And like many medicinals in history, arsenic was used for a hell of a lot that didn’t make sense: fevers, stomach pain, heartburn, rheumatism, and as a general tonic. From Aiken’s Tonic Pills to Compound Sulphur Lozenges to Gross’s Neuralgia Pills, the quackery-laden patent medicine trade was loving arsenic in the eighteenth century,” say the authors.

Despite frequent accidental or malicious deaths by arsenic, it maintains a legitimate place in pharmacopeia. “Salvarsan, neosalvarsan, and bismarsen are all arsenical compounds that finally brought syphilis to a stop after centuries without a cure. Eventually, penicillin usurped their place,” Kang and Pederson write, but “white arsenic has been used to treat acute promyelocytic leukemia, and is curing many patients today.”

“Quackery” details “nature’s gifts” to health care: opiates, strychnine, tobacco, cocaine, alcohol and Earth, the eating of dirt. The history of opiates continues to resonate today. It begins with poppies producing raw opium and its power to anaesthetize and addict. This led 15th century celebrity physician Paracelsus to invent a “safer” refinement of opium: laudanum.

Opium devastated China, but America found its weakness in laudanum, a tincture containing 10-percent powdered opium. “The addition of alcohol only intensified the euphoric and mind-altering effects. The products were touted by most physicians and obtainable without a prescription, used in the comfort of the home—no opium den required.”

But addiction remained: laudanum or other opium elixirs and nostrums never found acceptance by physicians. In answer, a young chemist created a new extraction from the poppy pod in 1803. He named it after the Greek god of dreams, Morpheus. Say hello to morphine.

Its adoption by physicians was in time for the Civil War, when huge quantities of morphine and opium healed and hurt in equal measure.

And then came a new instrument to introduce it to the body: the hypodermic syringe. “By the 1880s, (the) invention brought on new creations: morphinomania and morphinism, terms for morphine

Calomel remained in British pharmacopoeia until the 1950s.

addiction. The syringe was a miracle for medicine, but unfortunately a vehicle for a dark disease.” Back to the drawing board.

In 1874, a London pharmacist searched for a version of morphine without the addictive qualities. His new formulation, diacetylmorphine, was potent but wouldn’t be adopted until a Bayer Laboratories chemist wanted a product stronger than the aspirin they ‘reinvented.’

Bayer’s chemist experimented with the pharmacist’s diacetylmorphine, and after testing on rabbits and frogs, tried it on Bayer employees.

“They loved it. Some said it made them feel mighty, or heroicsh (heroic, German).” They called it heroin. Bayer immediately touted heroin as a cure for morphine addiction.

“Quackery” also covers surgical instruments. An Antidotes Hall of Shame: bloodletting, lobotomy, cautery, enemas and clysters, leeches, cannibalism and corpse medicine and therapies which defy modern imagination.

“Quackery” would be an interesting read at any time, but our times give it particular pertinence. We follow a year in which significant discussion was given to internally introducing UV light. A year in which people accidentally ingested chloroquine phosphate, a poisonous fishbowl cleaner, mistaking it for an anti-malarial drug. There has been no better time to read Kang and Pedersen’s review of medicine’s steps and missteps, and reconsider current events in light of history’s vagaries.

All quotes and images from “Quackery: A Brief History of the Worst Ways to Cure Everything” by Lydia Kang and Nate Pedersen, Copyright © 2017, Workman Publishing Company. Kindle Edition.

David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

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SAN ANTONIO MEDICINE

OMT in Practice: An Anecdote from a Third-Year Medical Student

By Travis B. Fenlon

Following my successful outing of seeing patients by myself for an entire day, I strolled into the office with aplomb. Despite my timorous reservations and growing pains of what only amounted to my first week of clinicals, I felt as if I were a health care provider. Was this normal? Was it right to feel this way? It didn’t matter. No time for hesitance; we had 30 patients and I wasn’t going to waste my newfound confidence.

Our first patient was a 69-year-old male following up on lab results for hypertension. His slicked-back hair was reminiscent of that of George Carlin in the later years, but our patient’s posture and muscle atrophy were far from risible. As my preceptor was counseling him on starting low-dose losartan, something called out to him to start palpating the man’s neck and shoulders—boom, trigger points. Delving a little more into his history revealed osteoporosis, a sedentary lifestyle and diffuse musculoskeletal pain. He was barely able to flex his hips for us from a seated position. As my preceptor started explaining that he wanted him to see either a chiropractor or massage therapist, I jumped at the opportunity: “Actually, would you mind if I worked on him?” His head turned, eyebrows rose and he smiled with his eyes before explaining to our patient who I was and what osteopathic manual manipulation could do for him. He consented to treatment; this was my big break!

Within seconds, I had a working osteopathic structural diagnosis: severely restricted active and passive range of motion in the cervical spine in flexion, extension, rotation and side bending with bilateral mus-

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cle hypertonicity and referred pain on deep palpation consistent with myofascial trigger points. I didn’t even bother trying to find somatic dysfunctions of his individual vertebrae; I wanted to go right into providing him relief. I eagerly jumped into the "Bilateral Forearm Fulcrum Forward Bending Method" technique. Said another way, I flexed his neck for 90 seconds. (Again, with an homage to Carlin: what's wrong with using honest, direct language?) He sighed with relief, so I figured I’d give the “Single Forearm Fulcrum Forward Bending/Side Bending/Rotation” technique a try on both sides of his neck. Again, more affirming sounds that the treatment was working.

After several minutes, I felt his neck again and the environment had completely changed from indomitable stone to a lissome water bed. I had him flip over on his stomach and I proceeded to do “Unilateral Prone Pressure” bilaterally along the length of his cervical and thoracic spine. The aural signs of relief entered the room again. I reevaluated him after about ten minutes of working; his range of motion significantly improved, and the trigger points were gone.

When he got up from the table, I told him that I felt a few of his vertebrae were “out of whack” and I wanted him to seek out an osteopathic physician in San Antonio. “Sir, I want you to try to find anyone who has the initials D.O. after their name, okay? They will be better able to help you out than I can,” I said.

“I can do that, but where is your office? I’d like to schedule an appointment,” he said. It’s fortunate that we were still wearing masks in clinic, because my jaw dropped. I’m just a

SAN ANTONIO MEDICINE • September 2021

medical student, one who is only seven days into his first rotation, at that.

Just a few short hours later, a 70-year-old man came into the office for a follow up on his labs for hypertension and diabetes. He was on top of things, and even dropping two pounds and an HbA1c level within reference range wasn’t good enough for him. He had been experiencing low back pain after a car accident eight years prior, but was too claustrophobic to receive an MRI, so he wanted clearance to be sedated for his imaging procedure. He told my preceptor and me about shooting pains he was experiencing down his arms, and an inability to perform daily tasks without severe back pain. Before I could even ask this time, I heard, “Well, you’re in for a treat today! Did you check in at the spa up front? Because my medical student here will fix you up. He goes to an osteopathic medical school, and they specialize in a lot of extra techniques that we do not learn in a traditional medical school.”

Our patient immediately consented to treatment and started to unbutton his shirt before my preceptor left the room. I evaluated him and had the identical diagnosis of the previous gentleman I had seen earlier.

I was getting into a rhythm at this point, so I remembered to actually talk with my patient this time. It turns out he had a storied history with massage therapists. I frantically asked him if I was doing okay, and he ecstatically responded in the affirmative.

Once I was done, I directed him to lie down on his stomach, but he told me that would be a problem. He had not been able to do this since before his accident. I helped him get into a position he was comfortable

SAN ANTONIO MEDICINE

with: planking. I had never tried a prone technique with a patient tensed up like this before, but I figured it was worth a shot. I hoped what I was doing wouldn’t be considered barmy. I worked on him from that planking position for a while, and with each passing minute, I noticed his forearms slipping. With all the sighs he let out, I asked if he was getting tired or in any pain. He responded that the sounds he was making were all good ones, and that he had not felt this way in years. He asked if he could tell me something confidential—something he had yet to even tell my preceptor. Mere minutes of hands-on treatment elicited a relationship so strong, he felt he could tell me things in confidence that he had never been able to tell anyone. Before I knew it, his arms dropped, and he was flat on the table—he hadn’t been able to lie down on his stomach

for eight years without pain. “Sir, you have a healing presence in your hands, I want you to know that. You’ve changed my quality of life,” he said.

I fought to plug the dam that was beginning to give way in my eyes. I told him that was the best compliment I had ever received in my medical career. I reevaluated him, and his tension was gone. I told him we were done for the day, and he asked if he could schedule a follow up appointment with me sometime in the near future. He asked when I was going to open up a practice here in San Antonio, so that he could be my first patient.

I was speechless and perhaps that was the way I should have stayed, for everything I was trying to weave together came out as doggerel. I tried to explain to him that I wanted to be a pathologist—a laboratory scientist—and that I was eyeing to move up

north for my residency. “Ah, you’ll be back in San Antonio. We need you here,” he said.

I felt deracinated but still somehow genial as I cried on the way back to my apartment.

I lamented over the fact that my patient had been suffering for nearly a decade. I pondered how the course of his life might have played out if an additional 20 minutes could have been doled out to him somewhere along the way, by anyone. After all, there was nothing extraordinarily special about the techniques I performed, but to him, the 20 minutes I took to perform them meant everything.

Travis B. Fenlon is a third-year medical student at the UIW School of Osteopathic Medicine.

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SAN ANTONIO MEDICINE

LETTER TO THE EDITOR

If you would like to send a letter to the editor of San Antonio Medicine magazine, please email editor@bcms.org.

July 13, 2021 To the editor, I have enjoyed reading San Antonio Medicine (SAM) since late in the last millennium. The magazine is chock full of articles from the President’s message to the article from the BCMS Alliance through Steve Schutz’s must-read car reviews. SAM features a wide variety of articles of interest written by member physicians, medical students, BCMS staff and supporters. That said, it’s missing something: Where is the ‘letters to the editor’ section?

I have yet to meet a medical student or physician in San Antonio who doesn’t have at least one and often many opinions on any subject.

Would it be possible to institute a ‘letters to the editor’ section in a forthcoming SAM so we all can read what our colleagues are thinking? I know we will have to keep it respectful and pithy, but could we please give it a try?

Thank you for your consideration.

Sincerely, Adam V. Ratner, MD is a member of the Publications Committee Adam V. Ratner, MD and former President of the Bexar County Medical Society.

REFLECTIONS ON UGANDA – Kony’s Rock

By Averi White, MD Last year, when we arrived in Omoro District, our driver immediately pointed out Joseph Kony’s childhood home, a small hut like all the others we had already seen along the way. I wondered how this little quiet place had given birth to so much evil; how the other members of this community had felt the day Kony banged two rocks together atop a plateau, now called Kony’s rock, declaring himself a god. The homes of the children in this picture were identical to the hut Kony grew up in, back up to Kony’s rock. Their parents described the banging noise and their terror as Kony sat atop his rock, using the Acholi people below as target practice. Eventually, they fled to refugee camps. For years, even after families returned from the refugee camps, people were scared to climb the rock. However, in the last few years, the local people have slowly but surely reclaimed the rock. Today, the rock is a reminder of the endurance and bravery of the Acholi people.

In this photograph, a new generation looks out across the beautiful Acholi land from atop the rock.

Averi White, MD is a PGY-2 Resident in the Internal Residency Program at UT Health San Antonio.

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SAN ANTONIO MEDICINE • September 2021

Children atop Kony’s Rock, Gulu

SAN ANTONIO MEDICINE

55 Word Stories:

Learning from our Youngest Patients…Guiding Them and Their Families on the Path of Healing

By Medical Students at the UT Health Long School of Medicine

Medical students at UT Health Long School of Medicine use the writing of 55-word stories to reflect on their clinical experiences.

A Mom’s Goodbye Child is coming into trauma tonight.

You read a pager.

First time doing CPR and you don't stop until told to.

You imagine a future for him.

You imagine how his smile would look or how his laugh would sound.

You know it doesn't look good.

Mom comes in.

“Baby. My baby. Not my baby.”

Reflection: This was one of the hardest cases I was involved in while on my trauma shift. It was my first time doing CPR on a child, and just seeing him bleeding and intubated was a really hard thing for me. Physicians allowed the mom to see the child in the trauma bay to begin the process of saying goodbye. It reminded me how short life is and how sometimes you can’t help the patient, but remember that you can help the family and comfort them. It reminds me to always put myself in their shoes and try to just be there for the patient and family. ~ Clarissa Meza, Class of 2022, Long School of Medicine, UT Health San Antonio

Is he okay? I think so He held her hand and cried She looked confused “What is going on?” she said.

No response.

The team talked in code.

She tried to make eye contact “Please, is he okay?”

A squeeze, a nod. “We think so.

He’s a fighter. He’s going up now.”

Less blue. A tiny cry.

We didn’t expect this.

Reflection: This experience was from one of the deliveries I observed while on my OB rotation. The mother was searching around the room looking for positive news about her newborn, but no one knew what to say. While the PICU team worked on the infant, the mother was crying and holding her partner’s hand, pleading for answers. The OB team was focused on making sure the mother’s bleeding was controlled. While one team worked on the newborn and the other worked on the mother, I felt that there needed to be more of a human focus on the mother and her son as an interconnected unit.

I wish I had known what to do or say in that situation. When the mother looked at me, I felt that I didn’t know enough about what was happening to offer her support or answer her pleas for information. As COVID has limited the amount of human- and thus emotional- support a birthing mother can have, it is extremely important that we continue to prioritize the patient’s emotional needs during an already overwhelming process. ~ Anonymous, Long School of Medicine, UT Health San Antonio

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SAN ANTONIO MEDICINE • September 2021

SAN ANTONIO MEDICINE

It’s better when you don’t know.

Hospitalized for weeks. Alone.

Technically an adult, but sitting in bed she looks like a child.

19 years old and terrified.

Unexplained infections, painful debridements, fevers.

What could be causing all this in someone so young?

She watches TikTok videos and worries about how swollen her face becomes.

Until we say the dreaded C word.

Reflection: She was only 19 years old and alone in that hospital bed for over a month. We would often find her watching videos on her phone and trying to keep her spirits up. She was really struggling emotionally, even before the cancer diagnosis of an aggressive form of leukemia. This patient really has stuck with me. She is so young and is going up against this horrible cancer. It’s hard to watch people younger than you going through these terminal illnesses and imagining yourself in that situation. I will use this experience to make me a better physician by reminding myself to take time to slow down and have real human conversations with my patients. These are the hardest days of their lives and they have to spend a lot of their time alone. Even though I am providing them medical care, my care should include their emotional and spiritual well-being. ~ Jessica LaRouere, Class of 2022, Long School of Medicine, UT Health San Antonio

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SAN ANTONIO MEDICINE

Empowering the Health Care Consumer

By M. Reza Mizani, MD

Spiraling out-of-pocket costs and intermediaries have put 1 of 4 Bexar County residents in medical debt. The time has come to restore the direct relationship between provider and patient.

The medical debt crisis in Bexar County Although every single person reading this article has received a “surprise” medical bill at some point in their life, very few know the magnitude of the medical debt crisis in Bexar County.

According to the Urban Institute’s interactive debt map, as of March 31, 2021, approximately 43% of Bexar County residents – two out of every five people – have medical debt in collections averaging $2,099. As with many aspects of health care, the impacts on underserved and minority communities are even more dire. According to RIP Medical Debt, a national nonprofit that abolishes medical debt for pennies on the dollar, Bexar County has over $100 million dollars of medical debt in collections. Surprise medical debt affects people at all income levels. According to a Lending Tree survey, medical debt has prevented 72% of families from reaching milestones in life such as buying a house or having children.

Surprise bills and medical debt are symptoms, rising costs and care deferment are the epidemic How did we end up here? We may or may not actually be getting sicker, but the costs of getting better have become much higher.

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Our health insurance has rapidly put the cost burden on the patient in terms of rising deductibles, premiums and co-pays. How much has the burden shifted? Consider this chart from the Kaiser Family Foundation that demonstrates the inflationary effects since the passage of the Affordable Care Act since 2009.

The above statistics show how this rapid cost escalation has pushed the payment burden onto the patient in terms of out-ofpocket expenses. It is also easy to see why so many families default to the “maybe it will get better” approach to health care, which may mean not seeking care at all. According to a Harris Poll in 2019, 54% of Americans will defer seeking health care due to concerns about cost.

The path from there is very linear: the illness either does “get better,” or it turns into a ride to an urgent care or ER. By the time this patient seeks care, it could be time for surgery or a stay in the hospital. This treatment now undoubtedly leads to large fol-

SAN ANTONIO MEDICINE • September 2021

low-on bills for a host of different services and providers which, according to a 2021 Credit Karma survey, over 60% of American families cannot afford to pay immediately. These unpaid bills then become medical debt, which can often lead to bankruptcy. How often? Depending on the annual data above, it is calculated that 67-70% of all consumer bankruptcies are medical debt-related.

When health insurance is no longer insurance Many will assume that these bankruptcies are being filed by Americans without insurance, currently estimated to be some 31 million people, (pre-COVID numbers). What will shock most is that of those medical debt bankruptcies, 68% of those that filed bankruptcy due to medical debt had health insurance at the time of injury or illness. So how does this happen?

This goes back to the rising costs illustrated above. But with real wages and sav-

SAN ANTONIO MEDICINE

ings not keeping pace, there is a growing group of people: the “functionally uninsured.” In short, if a family’s health insurance plan deductible exceeds their available savings, they are functionally uninsured. For most working age adults that are younger and healthy, perhaps this imbalance is never noticed. But should that same family face a catastrophic illness or suffer a major injury – such as a ruptured appendix – they will quickly find themselves incredibly burdened financially, and perhaps become a bankruptcy statistic themselves.

For many years, employer-sponsored health insurance (ESI) had plenty of value and utility. So many Americans with ESI were conditioned to see their health insurance card as a credit card. The first thing the medical receptionist would ask after hello is, “who is your insurance with?”

While much of the focus on solving the issues of surprise billing and medical debt focuses on the patients, you may have a hard time finding physicians that are fans of the current state of insurance-driven health care either. Billing, coding, negotiating, collecting – this is a system that has created billing- and insurance-related (BIR) costs of $0.17 on every dollar spent for private insurance payers. On top of the waste and excess cost, the time this BIR administration takes means less time and attention for actual patient care: the reason most become physicians and health care providers to begin with.

Restoring the direct relationship between the health care consumer and the provider Prior to World War II, most Americans paid their providers directly out of pocket at the time of service. When they required insurance to assist, it was often with fixed-fee costs. One nurse could support the patients, the front office and perhaps even a couple

physicians at one time. Above all else, the relationship between the physician and the patient was direct; there were no intermediaries between illness and care. In other words, before the advent of the health insurance industry, there was price transparency and a direct relationship between the physician and the patient.

Today, the patient has become the consumer, and change is now being driven from the outside where “innovation, not regulation” is the answer. Some innovations are within the insurance industry offerings themselves, such as defined contribution health care plans, which employers large and small are rapidly demanding and embracing. There are also many physicians opening subscription-based “direct primary care” model practices that remove the intermediary.

Price transparency, direct access and convenience are the keys to greater consumer participation, and the biggest advancements for the new health care consumers will come through technology. Our smartphones have irrevocably changed the human existence, and if in an Uber analogy we think of insurance-driven health care as the “old taxi” that everyone complains about, then the solution, represented in apps like LASO, should be similar: a free market platform with upfront pricing, direct access to physicians and convenient booking right from a mobile device at the time and place convenient to you. When we accomplish this, seeking the care you need now will then be as easy as “getting a ride in minutes.” With the participation of innovation-minded partner physicians in this effort, we can make a lasting impact on how retail health care is delivered, and simultaneously end care deferment and the scourge of medical debt.

M. Reza Mizani, MD is the founder and CEO of South Texas Renal Care Group. LASO Health is a health technology startup founded in San Antonio by Dr. Mizani, and is currently seeking health and wellness providers of all kinds to join them in their effort. For more information on becoming a LASO provider, visit https://www.lasohealth.com/md-partners/ or call (210) 624-7715.

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BANKING

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FINANCIAL ADVISOR

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Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services.

Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying.

For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies.

SWBC’s services supporting Physicians and the Medical Society.

Michael Leos Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent & treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options.

Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the

continued on page 40 Visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 39

state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior).

Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience.

Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our in-

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vestment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates).

Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems.

Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice.

Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.”

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

SAN ANTONIO MEDICINE • September 2021

MEDICAL PHYSICS

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking.

Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT

Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare.

Elevate the Level of Remote Care.

Enhance the Patient Experience.

Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud.

Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying.

For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies.

SWBC’s services supporting Physicians and the Medical Society.

Jon Tober

Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing,

and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates).

Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions.

Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management.

Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease” The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center.

Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

RETIREMENT PLANNING

cial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELEHEALTH TECHNOLOGY

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud.

Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare.

Elevate the Level of Remote Care.

Enhance the Patient Experience.

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties.

For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored finan-

Visit us at www.bcms.org

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AUTO REVIEW

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SAN ANTONIO MEDICINE • September 2021

AUTO REVIEW

2021 PORSCHE 911

By Stephen Schutz, MD

The Porsche 911 was first introduced at the Frankfurt Auto Show in 1963 and reached series production in 1964. After two generations and 17 years of success, the 911 was scheduled to be phased out, but was famously rescued in 1981 by then CEO Peter Schutz (no relation) before evolving into the automotive icon it is today.

About two years ago, the eighth generation 911, the 992, was launched, and it is turning out to be very popular, maybe the most popular 911 ever.

How popular is it? Porsche San Antonio General Sales Manager Matt Hokenson told me recently that if you order one now, you’ll need to wait more than a year for it to arrive (that will presumably change as the chip crisis currently bedeviling car manufacturers eases).

The exterior design of the new 911 is, no surprise, evolutionarily.

The timeless silhouette is instantly recognizable, as are the low front end, front fenders that stretch forward to connect with the round headlights and squatting rear end. But look closer and you’ll notice many retro design elements that look backwards as much as the rest of the styling points to the future. The hood, for example, mimics the classic G-body 911s of the 1970s and ‘80s, as does the full width red light bar that connects the taillights.

Inside the 911, Porsche followed its corporate cousin Audi into the screens-everywhere world, but they did it half-heartedly (thank you Porsche). While Audis give you one big screen right behind the steering wheel where the gauges used to be, Porsche combines a large central analog tachometer with two small screens on either side of it, along with a central touch screen. And while some manufacturers make sure that their screens welcome you with little CGI “movies” when you start the engine, Porsche just turns on what you selected previously.

No theater and no drama.

Another nice touch is the steering wheel. Too many manufacturers of sporty cars (and even SUVs) include a thick steering wheel in their vehicles, as if gripping a beefy wheel will reinforce in your mind the idea that whatever extra you paid for, the more athletic package was worth it. Whatever, Porsche doesn’t do thick steering wheels. They give you what they think works best.

When Porsche says “works best” they mean it enhances the driving experience. Porsche used to only make sports cars that drove the way they thought sports cars should. And they built a solid following doing just that. Then they realized that limiting their products to sports cars was a ticket to extinction, so they introduced SUVs and a sedan.

Nothing wrong with that, those non-sports cars saved the company.

But the heart of Porsche remains the rear engine, flat six cylinder, twoplus-two-seater 911 sports car. Which still drives really well, almost 60 years after it first saw the light of day way back in 1963.

I drive many new cars every year, and few are genuinely “different.”

The 911 is different. You start the engine by turning a “key” located to the left of the steering wheel, and immediately you hear the sound of the flat-six engine, which has a distinctive exhaust note that’s different from every other engine. And, of course, the sound comes from behind you, which is also different.

Then you drive the 911, and it handles uniquely because so much of the mass is at the rear of the car, unlike so many front- or mid-engine sports cars. Over the years Porsche engineers have used software and many other tricks to get rid of the off-throttle oversteer that used to haunt older 911s, and now the latest version corners amazingly well but also in a way that feels different from other sports cars. I recently drove a BMW M3 Competition, which has about the same power as a 911 Carrera S and was struck by how front-heavy the Bimmer felt in comparison. That is not to disparage the M3, but rather an observation that driving a 911 doesn’t feel like driving other performance cars.

Another different “thing” about the 911 is that most customers configure their cars and then order them, rather than picking them off the lot. And since the number of available options is gigantic, almost no two 911s are the same. I invite any doubters to sit down with their iPads and the Porsche configurator and see what I mean.

By the way, I can’t predict what your configuration will look like, but I can guarantee it will be expensive (the 911 starts at around $100,000).

58 years after it was introduced, the Porsche 911 remains the best all-around sports car available. And it’s as desirable as ever because it’s unlike everything else out there, and because it feels just right. If you can afford it, it’s worth every dime.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

Visit us at www.bcms.org

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of July 26, 2021.

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SAN ANTONIO MEDICINE • September 2021